Give one example of health-related data (a variable) that can be represented by a pie chart.
Do the same for a bar chart and a histogram. Explain why each data example you selected
(there will be a total of three different variables) is well represented by the corresponding
Critical Appraisal of Evidence-based Guideline by Use of the Agree Tool
Reducing the pain of childhood vaccination
This paper discusses the appraisal of a clinical based practice guideline for pain reduction
in childhood immunization. In doing so, the developers employ the Appraisal of Guidelines,
Research and Evaluation in Europe (AGREE) tool. The efficiency and quality of clinical practice
guidelines differ. The difference may be in form of format, presentation, and methods used in
literature review. Despite the variations, most guidelines are crucial to health care since they
use a vast range of evidence in making recommendations. The main aim of the AGREE tool is
to offer a basis for evaluation of the guidelines in clinical practice and verify their applicability
and quality to the healthcare practice (Cluzeau, 2001).
Key Words: Appraisal of Guidelines Research and Evaluation in Europe (AGREE) appraisal
Instrument, childhood vaccination, practice guidelines
Evidence-based practice (EBP) necessitates that nurses are acquainted with the
knowledge in appraisal systems. This is beneficial especially in finding as well as utilizing the
same in offering patient -centered care (Melnyk, Fineout, 2005). Owing to the increased number
of guidelines that are continually published, it is essential that nurse practitioners recognize
effective and quality practice guidelines at which to frame their practices. Clinical guidelines that
are based on methodical reviews of controlled experiments that are randomized are referred as
REDUCING PAIN IN VACCINATION: APPRAISAL 2
level 1 evidence. This is the most meticulous type of evidence available in clinical practice.
Poolman et al (2009) explains that efficient guidelines will assist clinical practitioners to
incorporate their acquired evidence into nursing practice. Poolman et al continues that the
importance of CPGs in clinical practice cannot be emphasized. This owes to the fact that they
serve as an instrument for patient management and therefore, contributes to the enhanced patient
care through implementation of evidence-based practice (Jarrett, 2009). It is highly beneficial for
health practitioners to be knowledgeable and adhere to the evidence based guidelines in order to
improve the patient care.
This paper was specifically written to explain the outcome of the appraisal on pain
reduction on childhood immunization guideline. Appraisers used the Appraisal of Guidelines
research and evaluation in Europe (AGREE) (AGREE collaboration, 2009) instrument in
conducting the appraisal. This tool offers a basis to evaluating the CPGs quality and verifies its
applicability in clinical setting and practice. Though there are other tools which may be
employed to grade the quality of CPG, the AGREE instrument is the standard criterion in this
aspect (Krainovich- et al 2009). Its reliability level of cronbach 64-88 is accepted in most of its
The agree tool is constituted of 23 questions that are organized in 6 domains. These
include purpose and scope, involvement of stakeholders, development rigor, presentation and
clarity, editorial independence and applicability. The appraisals graded the questions using a four
point scale of 1 strongly disagree and 4 strongly agree. The appraisers then calculated scores for
REDUCING PAIN IN VACCINATION: APPRAISAL 3
all the domains. In reliably evaluating the guideline by use of the AGREE tool, at least four
appraisers are require (Slutsky, 2005).
A score for each domain was calculated. These scores are separately presented and are
not employed in establishing a single quality measure. Independent scores of these domains may
trigger debate regarding the strengths and weaknesses of a specific guideline and therefore, assist
in making decisions on whether to accept or reject the guidelines.
In previous situations, the AGREE tool has been effective in assessing the CPGs quality
for nursing practice. For instance, surgeons, dentists and some physicians employed the
AGREE tool in finding out the best CPGs to be utilized in answering clinical queries on
whether to go on with the anticoagulation therapy and antiplatelet prior to performing dental
surgery(vanDiermen et al, 2009). In order to offer recommendations on how to care for diabetes
conditions by American College of physicians, a group of appraisers employed the AGREE
tool in their assessment of various guidelines of diabetes care. Apparently, a group of
multidisciplinary practitioners employed the AGREE tool in devising a workflow instrument for
patients that were about to undergo liver transplant (Quaseem et al, 2007). In essence, the
AGREE tool could assist clinicians to find high quality CPGs that can guide them in their
The appraisal team consisted of four nurse students. This is the required number to
perform clinical guideline appraisal using the AGREE tool. This team was apparently concerned
on finding out the best practice for nurse practitioners that could be used to minimize pain to
children during vaccination process. The team could be considered as innovative since it is the
REDUCING PAIN IN VACCINATION: APPRAISAL 4
first time student nurses have employed the AGREE instrument in determining the quality of
CPG through evaluation of the main domains of the AGREE instrument. The following part of
the paper explains the team’s assessment of pain minimization in childhood vaccination
developed by Taddio et al, (2010).
Purpose and Scope
Developers of pain reduction in childhood vaccinations guideline were interested in
designing a guideline that could be used by health practitioners in minimizing pain during
vaccination. The clinical guideline so developed was based on literature reviews on the subject
of distress and pain in children during vaccination. The literature scope was only limited to acute
distress and pain during and after vaccinations for children under 15 years. Although significant
clinical queries concerning pain reduction were addressed in the guideline, the most
comprehensive discussion was based on the clinical recommendation presented. In other words,
the guideline addressed the queries related to pain and distress in childhood vaccination.
However, although findings from literature review are comprehensively covered, information or
input from the other respondents such as parents, scientists, and policy makers is not clearly
presented in the guideline.
The pain reduction guideline was developed by an interdisciplinary group termed as Help
eliminate pain in kids (Help In Kids). This group was responsible in choosing panel members,
which included experts and individuals from a diverse background and disciplines in Canada.
These included pediatric medicine organizations such as Toronto public health, Canadian
REDUCING PAIN IN VACCINATION: APPRAISAL 5
Pediatric society and the Canadian center for vaccinology. Other stakeholders included the
policy makers in Canada, clinicians, and scientists on the following disciplines: pediatric,
evidence based therapies, health policy, education, guideline development and translation of
scientific knowledge. In addition, the parents were also involved to provide their qualitative and
quantitative input on the proposed guideline (Parvez, 2010).
While the AGREE tool emphasizes on consideration of the views and preferences of
the patients , the guideline presented by Teddio et al is focused on clinician’s perspective of
minimizing pain in children during vaccination. The guideline failed to consider the views and
preferences of the children (since some of them are older) and their parents and incorporate or
determine on how to address such preferences and views. In essence, clinical guidelines should
be developed keeping in mind the health outcomes of patients and their families. Another note is
that there was no pilot testing conducted or if so was not described in the guideline to ascertain
the validity of the information before being published. The current appraisal on pain reduction on
children vaccination will ensure that relevant information that was obtained from stakeholders
are presented from the stakeholder. Views will also be sought from children older than 10 years.
In addition, the guideline will be first piloted before it is released to the users.
The developers of pain reduction in childhood vaccination guideline employed systematic
methods of literature review, interviews with main informants as well as discussion with
stakeholders and panel members in finding the evidence (Harris, 2001). Thirty-two questions
were designed and considered in the guideline. However, this number was subsequently reduced
to 18 to concur with the evidence base. The chosen panel members were responsible for
REDUCING PAIN IN VACCINATION: APPRAISAL 6
performing systematic reviews and Meta analysis. However, the evidence was limited to
randomized and controlled experiments and reviews that were quasi experimental in nature.
Moreover, the developers employed the Cochrane risk of bias instrument in establishing the
quality of the studies that were reviewed. The evidence was appraised and recommendations by
use of the evidence based techniques postulated by the Canadian Task force on preventive
health. The developers based their recommendations on the strength of the scientific evidence in
the studies. In general, the panel reviewed 71 studies, which included 8050 kids.
In this guideline, it can be said that the technique used by the developers in coming up
with the recommendation were clearly presented. Every statement was rated according to the
evidence level. Hence, there was a clear connection on the supporting evidence and
recommendations of the developers. The health benefits of pain reduction during child
vaccination were however not considered during development of the guideline. Though the
guideline contained intervention measures for both clinicians and parents to reduce pain during
vaccination, it failed to address the various risks associated with such interventions and treatment
Developers of this guideline presented the draft to external reviewers who included the
Nursing Coalition for immunization in Canada, Canada Coalition of Immunization, promotion
and awareness, the Canadian Pharmacist Coalition, the Canadian nursing coalition for
immunization, college of family physicians and the Canadian pharmacist association. After the
external reviewers were through with their work, developers incorporated their suggestions in
the final document. This means that the guideline is a reflection of both the panel members, and
evidence review group. However, developers did not indicate the procedure to be adhered with
regard to updating the guideline when it becomes necessary.
REDUCING PAIN IN VACCINATION: APPRAISAL 7
REDUCING PAIN IN VACCINATION: APPRAISAL 8
Cluzeau,F( 2001). “Appraisal of Guidelines for Research &Evaluation”
Harris RP, Helfand M, Woolf SH, (2001). “Current methods of the US Preventive Services
Task Force: a review of the process”. Am J Prev Med 2001;20(3 Suppl):21-35
Jarrett M. (2009), “Use of clinical practice guidelines to promote best practice when managing
clinical interventions for liver transplant patients” Prog Transplant. 2009;19(2):132–140.
Krainovich-Miller B, Haber J, Yost J, Jacobs SK. (2009), “Evidence based practice challenge:
teaching critical appraisal of systematic reviews and clinical practice guidelines to
graduate students” J Nurs Educ. 2009;48(4):186–195.
Melnyk BM, Fineout-O. E. (2005). “Evidence-Based Practice in
Nursing and Healthcare” Philadelphia, PA: Lippincott; 2005.
Parvez E, Stinson J, Boon H (2010). “Mothers’ beliefs about analgesia during childhood
Immunization”. Paediatr Child Health (Oxford) 2010;15:289-93.
Poolman RW, Verheyen CPM, Kerkhoffs GM, Bhandari M, Schunemann HJ. (2009). “From
evidence to action: understanding clinical practice guidelines” Acta Orthop.
Quaseem A, Vijan S, Snow V, Cross JT, Weiss KB, Owens DK. (2007). “Glycemic control and
type 2 diabetes mellitus: the optimal hemoglobin A1C targets”. American College of
Physicians. Ann Intern Med. 2007;147:417–422.
Slutsky J. (2005). “Using evidence-based practice guidelines: tools for improving practice”.
Philadelphia, PA: Lippincott; 2005:221–236.
Taddio A, Appleton M (2010). “Reducing the pain of childhood vaccination:
an evidence-based clinical practice guideline”, Canadian Medical Association, 182(18).
The Agree Collaboration, (2009), “Appraisal of Guidelines for Research and Evaluation in
Europe (AGREE instrument)” Available from www.agreecollaboration.org.
VanDiermen DE, Aartman IHA, Baart JA, Hoogstraten J, vanderWaal I. (2009).”Dental
management of patients using antithrombotic drugs: critical appraisal of existing
guidelines”. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2009;107:616–624.